Which of the following st u dies may be h elpfu l t o det ermin e if the pat ient h as ret ain ed splenic funct ions following h is operat ion? W hich of the following is the most appropriate recommendat ion for this pat ient at t his t ime? Laparoscopic splenectomy because she has a favorable but unsustained response to steroids therapy B buy 1000mg cipro with visa taking antibiotics for sinus infection while pregnant. Sinistral portal hypertension refers to left-sided portal hypertension buy cipro 750mg amex antibiotics gain weight, which is associated with thrombosis of the splenic vein buy generic cipro infection near eye. Under this circum- stance, blood flow from the spleen has to return to the central venous system through the short gastric veins resulting in marked dilatation of the short gas- tric veins (gastric varices). T h e p er ip h er al sm ear can b e h elp fu l t o d et er m in e if this patient h as m ain - tained splenic functions following his injuries and surgery. A platelet count of 40,000 mm is not gen er ally con sid er ed so cr it ically low that it would r equ ir e sp ecific t r eat m en t. Continued monitoring for bleeding symptoms and further drop in platelet cou nt is the best appr oach at this t ime. The explanat ions t o t he answer choices describe t he rat ionale, including which cases are r elevant. A53-year-oldmanpresentstotheemergencydepartment with4-dayhis- tory of nausea and vomiting. The patient reports that he has not been able to tolerate any food or liquids by mouth over this period of t ime. The emergency medicine provider not i- fies you that the p at ient h as some sign ifican t ly abn or mal ser u m labor at or y valu es. Start Lactated Ringers at 200 mL/ h and titrate to keep a urine output of 30 to 50 mL/ h B. Start 5% salt-poor albumin at 100 mL/ h and continue until his sodium normalizes R-2. Shedevelops acut e respirat ory insufficiency during hospit al day 1 t hat required endot ra- ch eal int ubat ion an d mech an ical vent ilat ion. O n h ospit al day 3, sh e st abi- lizes from the h emodynamic st andpoint and remains on the vent ilat or. O n examinat ion, she is awake wit h abdominal dist ension and some epigast ric tenderness on examination. She is expected to require mechanical ventila- tion for several more days based on the intensivist’s best estimation. Placement of feeding jejunostomy tube by laparoscopy and initiate feeding on ce the t ube is placed R-3. A 73-year-old woman with past history of diverticulitis presents to the emergency cent er wit h fever, abdominal pain, abdominal t enderness, and hypotension (blood pressure of 90/ 50). The patient reports that the pain is ver y sim ila r in p at t er n, lo cat io n, a n d ch a r act er ist ics t o h er p r evio u s b o u t s o f diverticulitis. Which of the following choices represents the best sequence of prioritized t reatments for this pat ient? Lab o r at o r y b lo o d wo r k s, I V flu id s, C T scan of ab d o m en an d p elvis, surgical consult at ion and broad-spect rum ant ibiot ics C. A 24-year-old man suffered deep partial-thickness burn wounds to the ent ire ant erior ch est and abdomen, and circumferent ial burns t o bot h arms wh en h is clot h es caught fire at a barbecue pit. Based on the P ar klan d for m u la for b u r n patient r esu scit at ion, wh at is the est imat ed volume of fluid t o be administ ered for t he init ial 8 hours? W hich of t he following operat ions is t he most appropriate for this patient with this condition? A43-year-old man with a12-cm distal,right thigh massarisingfrom the anterior thigh muscle compart ment undergoes core needle biopsy of the mass, which reveals moderately well-differentiated liposarcoma. Which of the following choices is considered the most appropriate surgical approach for this patient? Wide local excision of the tumor with a 2-cm margin including right gr oin sent in el lymph n od e biop sy D. Wide local excision of the tumor with a 2-cm margin including right gr oin lymph n od e dissect ion E. A63-year-oldmanwithhistoryofhypertensionandcoronaryarterydisease presents for the evaluation of pain in his right calf whenever he attempts to walk more than one cit y block. Because of this pain, he has been having significant problems performing daily act ivit ies, such as shopping, going to the bank, and going to visit friends. Despite your advice for him to stop smoking, he cont inues t o smoke one and a half packs of cigarett es daily. The examination of his peripheral pulses reveal normal femoral pulses bilaterally, normal left popliteal and pedal pulses, and absence of right pop- lit eal and pedal pulses. T h ere is no evidence of crit ical t issue isch emia in eit h er lower ext remit y. W hich of t he following diagnost ic st udies is the most appropriate next step for this patient? A63-year-oldwoman isbrought totheemergencydepartment after being foun d t o h ave collapsed in side h er h ome. H er family repor t s that sh e st ayed home from work because she woke up with upper abdominal pain and chills. An ultrasound of the abdomen reveals no free fluid in the abdomen, normal abdominal aorta, gallstones in the gallbladder, and dilatation of the intrahepatic bile ducts. Whichofthefollowingpatientswithmassoftheheadofthepancreasisa can did at e for su r gical r esect ion? A 43-year-old woman with a 2-cm mass in the head of the pancreas and a 2-cm lymph node along t he lesser curve of t he mid-body of the st omach. A 46-year-old woman who underwent pancreaticoduodenectomy 14 months ago presents with new 1-cm lesion in segment 2 of the liver. A 43-year-old woman with a 12-cm cystic neoplasm in the body of the head and body of the pancreas. Imaging studies demonstrate invasion of the dist al stomach, left kidney, left adrenal gland, and the aort a R-10. A 59-year-old post men opau sal woman is foun d on h er an nual mam- mogram to have a cluster of suspicious pleomorphic microcalcifications. A stereotactic image-guided core needle biopsy was performed, and the radiologist reports that 15 separate core biopsy specimens were obtained. Pathology of the core needle biopsy procedure revealed benign breast tissue wit hout evidence of malignancy. W hich of t he following factors is helpful in det ermining t hat t he lesions are benign? Two sent in el lymph n odes an d t wo en larged n on sent i- nel lymph nodes were identified and removed. T h e false n egat ive r at e of sen t in el lym p h n o d e b io p sies is 1 0 % C. Random lymph node sampling yielding more than 2 negative lymph nodes from the axilla is sufficient for axillary staging D.

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It may be more challenging than "the most likely diagnosis buy cipro australia antibiotics for dogs gums," because there may be insuficient information to make a diagnosis and the next step may be to pursue more diagnostic information buy cipro once a day bacteria stuffed animals. Another possibility is that there is enough information for a probable diagnosis and the next step is to stage the dis­ ease cheap cipro amex antibiotics buy online. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of: Make a diagnosis � stage the disease � treat based on stage � follow response Frequently, the student is "taught" to regurgitate the same information that someone has written about a particular disease, but is not skilled at giving the next step. Make the diagnosis: "Based on the information I have, I believe that Mr Smith has stable angina because he has retrosternal chest pain when he walks 3 blocks, but it is relieved within minutes by rest and with sublingual nitroglycerin. Treat based on stage: "Therefore, my next step is to treat with aspirin, B-blockers, and sublingual nitroglycerin as needed, as well as lifestyle changes. Follow response: "I want to follow the treatment by assessing his pain (I will ask him about the degree of exercise he is able to perform without chest pain), perfo rm a cardiac stress test, and reassess him after the test is done. The next step depends upon the clinical state of the patient (if unstable, the next step is therapeutic), the potential severity of the disease (the next step may be staging), or the uncertainty of the diagnosis (the next step is diagnostic). This question goes further than making the diagnosis, but also requires the student to understand the underlying mechanism for the process. The student is advised to learn the mechanisms for each disease process, and not merely memorize a constellation of symptoms. The platelets-antibody complexes are then taken from the circulation in the spleen. Because the disease process is specific for platelets, the other 2 cell lines (erythrocytes and leukocytes) are normal. Also, because the thrombocytopenia is caused by excessive platelet peripheral destruction, the bone marrow will show increased megakaryocytes (platelet precursors). Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding the risk factor analysis may help manage a 45-year-old obese man with sudden onset of dyspnea and pleu­ ritic chest pain following an orthopedic surgery for a femur fracture. This patient has numerous risk factors for deep venous thrombosis and pulmonary embolism. The physician may want to pursue angiography even if the ventilation/perfsion scan result is low probability. Thus, the number of risk factors helps categorize the likelihood of a disease process. A clinician must understand the complications of a disease so that one may monitor the patient. Sometimes the student has to make the diagnosis from clinical clues and then apply his/her knowledge of the sequelae of the pathological process. For example, the student should know that chronic hypertension may afect various end organs, such as the brain (encephalopathy or stroke), the eyes (vascular changes), the kidneys, and the heart. Understanding the types of consequences also helps the clinician to be aware of the dangers to a patient. The clinician is acutely aware of the need to monitor for the end-organ involvement and undertakes the appropriate intervention when involvement is present. To answer this question, the clinician needs to reach the correct diagnosis, assess the severity of the condition, and weigh the situation to reach the appropriate inter­ vention. For the student, knowing exact dosages is not as important as understand­ ing the best medication, the route of delivery, mechanism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy. A common error is for the student to "jump to a treatment," like a random guess, and therefore is given "right or wrong" feedback. Instead, the student should verbalize the steps so that feedback may be given at every reason­ ing point. For example, if the question is, "What is the best therapy for a 25-year-old man who complains of a cough, fever, and a 2-month history of 10 lb weight loss? Therefore, the best treatment for this man is either antimicrobial therapy such as with trim­ ethoprim/sulfa, or chemotherapy after confirmation of the diagnosis. Knowing the limitations of diagnostic tests and the manifestations of disease aid in this area. There are 4 steps to the clinical approach to the patient: making the diagnosis, assessing severity, treating based on severity, and following response. Assessment of pretest probability and knowledge of test characteristics are essential in the application of test results to the clinical situation. There are 7 questions that help bridge the gap between the textbook and the clinical arena. The focus of the infection is the urinary tract and that should determine the antibiotic choices. The presence of tachycardia, tachypnea, hypotension, hypoxemia, and low urine output combined with a decreased mental status are all responses to sepsis. To be familiar with the treatment strategies to correct abnormal vital signs and early goal-directed therapy. Co nsidertions The patient described in this scenario was about to be discharged from the hospital. The nurse called regarding abnormal vital signs, which were dramatically altered from normal. For instance, the oxygen saturation of 80% likely correlates to an oxygen partial pressure of 45 mm Hg, which is incompatible with life. This hospital has a rapid response team, which is a mul­ tidisciplinary team that assesses patients quickly when there are potential critical illnesses. A delay in assessment, recognition, or therapy could lead to adverse consequences, including death. The recently developed rapid response teams or medical emergency teams which consist of a group of clinicians and nurses, brings critical care expertise to the bedside. Their expertise has drastically reduced both the incidence of cardiac arrests and subsequent deaths. This has resulted in an increase in the number of patients who are discharged in a fnctional state. Scoring systems utilizing routine observations and vital signs taken by the nursing and ancillary stafare used to evaluate the possible deterioration ofpatients. This dete­ rioration is fequently preceded by a frther decline in physiological parameters. Fur­ thermore, a failure ofthe clinical stafto recognize this failure in respiratory or cerebral fnction will put patients at risk of cardiac arrest. Precautions to prevent aspiration such as elevation of the head of the bed to 30° to 45° should be instituted whenever there is a change in mental status, or increased risk of aspiration, provided the current blood pressure allows this. Cardiac arrest has been associated with the failure to correct physiological derangement in oxygenation (breathing), hypotension (blood pressure), and mental status (see Table 1-1). The respiratory rate varies with age, but the normal reference range for an adult is 12 to 20 breaths/minute. A narrow pulse pressure value is also caused by aortic stenosis and cardiac tamponade.

A. Arokkh. Southern Connecticut State University.